A STUDY OF THE IMPACT OF SPIRITUALITY, RELIGION AND FUNCTIONAL HEALTH OF THE ELDERLY A Dissertation Presented to the Faculty of the School of Health Administration Kennedy-Western University In Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy in Health Administration by Kendall Brune St. Louis, Missouri Table of Contents Chapter 1 – Introduction………………………………. 1 Introduction………………………………… 1 Statement of the Problem………………… 2 Purpose of the Study……………………… 3 Importance of the Study……………………4 Scope of the Study………………………… 6 Rationale of the Study………………………9 Overview of the Study…………………….. 1 Definition of Terms……………………….. 141 Chapter 2 – Review of Related Literature………….. 13 History of Religious Studies-Health Care…15 Demographic Trends in Health Care………16 Science & Religion…………………………… 23 Review-Religion in Medical School ……….. 26 The Relaxation Response: Harvard. ……26 Aging as a Spiritual Journey: Loyola……27 Faith- life-promoting: Emory…………….. 30 Physician & Religion: St. Louis…………31 International Center for the Integration of Health and Spirituality………………… …. 34 Centers for Disease Control………………35 Joint Commission on Accreditation of Healthcare Organizations (JCAHO) ……………………………………………….. 37
A Review of: Patient Satisfaction……………. ………….. 41 Spiritual Directives…………………………. 42 ii Health Outcomes………………. …………. 38 Spiritual & Emotional Needs………. …….. 40 Clinical Cohorts from Benjamins…………44 Clinical Cohorts from Daaleman…………. 45 Patients Desire for Religion………………. 47 Clergy Issues in Healthcare………………53 Ethical Issues in Healthcare …………. …. 56 Summaries &Conclusions. ……………….. 57 Chapter 3 – Methodology……………………………. 59 Approach of the Benjamins’ Study………. 61 Benjamins’ Conceptual Framework………61 Benjamins’ Study Mechanisms……………61 Benjamins’ Control Mechanisms…………. 62 Benjamins’ Social Resources ……………. 3 The Database of the Study……………….. 66 Variables in the Benjamins Study………… 71 The Approach of the Daaleman Study….. 75 Daaleman’s Conceptual Framework…….. 76 Daaleman’s Study Variables………………77 Daaleman’s Well Being Questionnaire….. 79 Summary……………………………………. 86 Chapter 4………………………………………………. 87 Demographics and Statistics……………. 89 The Data Analysis for Daaleman……….. 92 The Data Analysis for Daaleman……….. 94 Data Charts……………………………….. 96 Chapter 5………………………………………………108 Theory on Aging…………………………. 109 iii Recommendations/Action Items……….. 112 Spiritual Care & Assessment…………. 121 Role of the Physician………. …………. 21 Conclusion: National Impact of Studies…132 Final Comment…………………………. 136 Bibliography……………………………………………. I Tables and Charts…………………………………….. XVIII Chart 1: Faith Support Flowchart………………XVIII Table 1: Relative Risk of Dying, Strawbridge…XXI Table 2: Life Expectancy & Religious Activity…XXI Table 3: JCAHO RI. 1. 13 Care @ End of Life…. XX Table 4: JCAHO Reading Referrals to Patients. XXII Table 5: Benjamins Statistical Results…………. XXIII Table 6: Daaleman – Demographics……………XXV Table 7: Spirituality Index of Well Being………. XXVII Appendices…………………………………………….. XXVIII A: Joint Commission Regulations…………XXVII
B: SF – 12v1 Survey Description………….. LIII C: SES Descriptive Charts ……………….. LXIII D: Health Retirement and Survey Data…. LXVI E: JCAHO Spiritual Assessment Tool……CXXII F: Geriatric Depression Scale……………. CXXVI G: Spirituality Survey – 12-item Scale……CXXII iv Abstract of Dissertation A STUDY OF THE IMPACT OF SPIRITUALITY, RELIGION AND FUNCTIONAL HEALTH OF THE ELDERLY By KENDALL BRUNE Kennedy-Western University THE PROBLEM Religion is a source of comfort to some and a conflict to others. A study done by Gallop at Princeton claimed a vast majority of Americans (94%) claim to believe in God.
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Koenig’s study found among older Americans, 98% believe in God, and pray. Maungans, et al. found physicians tend to ignore religious issues in the care of their patients (Maugans, 1991. pp. 210-13). However, this trend is changing. As reported by Koenig (1999, p. 25) Hundreds of major scientific studies by other researchers have found statistical benefits to the consistant exposure to religion. The risk of dying from all causes is up to 35 percent lower for people who attend religious services once or more a week than for those who attend less frequently. This statistical significance has rompted two thirds of the medical schools to offer required or elective courses on religion, spirituality, and medicine. In the published medical literature, there is a conflict regarding the effects of religion on the functional health of older Americans. Sloan et al. reviewed the literature and found inconsistent and weak links between religion and health. In v contrast, the reviews by Levin and Schiller and by Larson et al. found positive effects of religion on physical and mental health. Koenig and Benjamins found in their clinical research that religion has a direct relationship with functional health.
Given this conflict, this study is a critical review of the medical literature and how two particular studies focus on whether the attendance at religious services has an inverse association with functional health among the elderly. The Daaleman study is a regional review of geriatric patients participating in a program at the University of Kansas Medical Center. Daaleman performed a cross-sectional analysis of 277 geriatric outpatients participating in a cohort study in the Comparatively, Maureen Benjamins from Kansas City area. the University of Texas at Austin developed a less involved tudy that is a longitudinal and cross sectional analysis of national data sets. Benjamins states it is critical to examine the possible differing effects of religion and functional health with the elderly population, because this age is rapidly expanding. More information on religion and functional health is also needed because the information is not conclusive, but rather conflictive. METHOD The goal of this study is to assess the impact (positive or negative) of religion on functional health outcomes. The Daaleman Study was a secondary analysis of cross-sectional data from a larger cohort study.
The parent study was designed to determine the feasibility of performance measures in predicting future health service utilization, health status, and functional status in older, community-dwelling primary care patients (Studenski, 2003). Patients underwent a home assessment of multiple health status, performance, and functional indicators by trained research assistants. A previously validated five-item measure of religiosity was utilized from the National Opinion Research Center in Chicago, and a twelve-item spirituality instrument developed in an earlier vi Daaleman Study (2002) were embedded during the final data ollection. The current study represents data collected 36 months after enrollment. Participants were older adults who were screened and recruited for the parent study between April and November of 1996 from primary care sites within a Veteran’s Affairs (VA) network (n = 142) and a Medicare health management organization (HMO) (n = 350) serving the Kansas City metropolitan area. The Benjamins Study used the Assets and Health Dynamics Among the Oldest Old Survey, a nationally representative, longitudinal data set, to estimate the effects of religious attendance and salience on functional health in the elderly.
The primary study hypothesis proposes that religious attendance and salience will be associated with a decrease in functional limitations for older respondents. FINDINGS In conclusion, the researcher presents the results of this study as a contribution to the growing body of knowledge regarding the issue of religion services and its positive impact on functional health of the elderly. The results of the current studies in review were consistent with the previous studies by Idler and Kast (1997), which also found that “more frequent church attendance is associated with lower levels of disability. Despite the limitations of the various studies, the preponderance of evidence supports the beneficial effects of religion on health outcomes. The need for ongoing research in this area is evident. Considering the elderly think religion is important, religion likely benefits health outcomes, and religion is without financial cost, health care providers should include religion in the care of their elderly patients. vii Chapter 1: Introduction Spirituality and Faith Communities Throughout history, humans have suffered ills and sought healing. In response, the two healing traditions— religion and medicine—historically have joined hands in aring for the sick. The same person often conducted these efforts; the spiritual leader was also the healer. Hospitals, which were first established in monasteries then spread by missionaries, often carry the names of saints or faith communities. As medical science matured, healing and religion diverged. Rather than simply asking God to spare their children from smallpox, people began vaccinating them. Rather than seeking a spiritual healer when burning with bacterial fever, they turned to antibiotics. It was a very logical progression, but has lacked the human compassion experience.
However, the separation between religion and medicine is now shrinking. “Spirituality” has made a comeback (Koenig, 2001, p. 25): • • • Since 1995, Harvard Medical School has annually attracted 1000 to 2000 health professionals to its Spirituality and Healing in Medicine conferences. Duke University, a leading Research Medical Institution in the United States, has established a Center for the Study of Religion/Spirituality and Health. 86 of America’s 126 medical schools offered spirituality and health courses in 2002, up from 5 in 1992 (Koenig, 2001). 1 • • 94 percent of HMO professionals and 99 percent of amily physicians agreeing that personal prayer, meditation, or other spiritual and religious practices can enhance medical treatment. (Yankelovich,1997) This renewed convergence of religion and medicine appears in such books as The Faith Factor (Viking, 1998), The Healing Power of Faith (Simon ; Schuster, 1999), Religion and Health (Oxford University Press, 2000), and Faith and Health (Guilford, 2001). Is there fire underneath all this smoke? Do religion and spirituality actually relate to health, as polls show four out of five Americans have believed (Matthews, 1997)? Statement of Problem: Does Faith Impact Health ;
Healing? More than a thousand studies have sought to correlate “the faith factor” with health and healing. Does religion significantly influence the health outcomes of the elderly? Very few studies have followed cohorts long enough to examine a cause and effect relationship. It is possible the increasing levels of religious participation may strengthen the functional health of the elderly (Benjamins, 2004, pp. 355-74). Kark and his colleagues in 1996 compared the death rates for 3900 Israelis either in 1 of 11 religiously orthodox or in 1 of 11 matched nonreligious collective communities (Kark, 1996, pp. 341-46).
The researchers reported that over a 16-year period, “belonging to a religious collective was associated with a strong protective effect” not 2 explained by age or economic differences (Kark, 1996, p. 345). Koenig and Larson have found religion has a salutary or protective effect on a variety of health outcomes. Despite numerous studies that indicate positive benefits from religious involvement, Sloan states the evidence is not empirical. It is the “Sharp Shooters Accuracy” model of study. If you take a sharp shooter out and have him fire six rounds into a concrete wall and then draw a target, the accuracy will be incredible.
Sloan believes it is hard to control for all the variables involved in religious beliefs. Purpose of the study The purpose of this study is to review two significant different cohort groups that were focused on the impact of religion on the health outcomes of elderly individuals. The first study was a large national longitudinal study completed by Benjamins at the University of Texas at Austin. One of the concluding remarks was that smaller, regional studies should be completed to accommodate for denominational influences over lifestyle and environmental variations. The second study in comparison is a small regional nalysis completed in a large midwestern metropolitan area. Daaleman and colleagues from the University of Kansas Medical Center completed a smaller regional study focused on elderly clients served through its outpatient clinics. In every age group, those belonging to the religious communities were about half as likely as their nonreligious counterparts to have died. To further understand the 3 relationship among religion, spirituality, and self-reported health status, Daaleman performed a secondary analysis of the parent studies cross-sectional data. Daaleman utilized a health status model developed by Johnson and Wolinsky s the research model to examine the relationship between self-reported health status and religiosity (Johnson, 1994). A similar large cohort study of 91,909 persons in one Maryland county found those who attended religious services weekly were less likely to die during the study period than those who did not—53 percent less from coronary disease, 53 percent less due to suicide, and 74 percent less from psoriasis of the liver (Comstock ; Partridge, 1972). In response to such findings, Sloan and his skeptical colleagues remind us that mere correlations can leave many factors uncontrolled (Sloan, 1999). Consider one bvious possibility: Women are more religiously active than men, and women outlive men. So perhaps this might suggest religious involvement is merely an expression of the gender effect on longevity. Importance of the Study Epidemiologist Strawbridge and his co-workers followed 5286 Alameda, California, adults over 28 years. After adjusting for age and education, the researchers found that not smoking, regular exercise, and religious attendance all predicted a lowered risk of death in any given year. Women attending weekly religious services, for example, were only 4 54 percent as likely to die in a typical study-year, as were non-attendees.
With the focus of health maintenance organizations centered on prevention and profit, religious activity might soon become a question for new insured’s (Strawbridge et al. , 1997, 1999; Oman et al. , 2002). A National Health Interview Survey (Hummer et al. , 1999) followed 21,204 people over 8 years. After controlling for age, sex, race, and religion, researchers found nonattendees were 1. 87 times more likely (See Table 1) to have died than were those attending more than weekly. This translated into a life expectancy at age 20 of 83 years for frequent attendees and 75 years for infrequent attendees.
Hummer showed regular attendance at religious services is associated with an additional eight years of life expectancy when compared to never attending. These effects of religious attendance were consistent across all age, gender, and race/ethnicity groups and for all major causes of death (Hummer et al. , 1999, pp. 273-85). Dychtwald, psychologist, gerontologist and entrepreneur, suggests the educated senior consumer desires to take charge of the quality of life by participating in his/her mental and physical well-being. If there is an increased awareness of positive mental and physical health enefits for seniors, marketing dollars will be redirected toward spiritual health in this growing demographic (Dychtwald, 2005). The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has acknowledged that patients’ “psychosocial, spiritual, and cultural values affect 5 how they respond to their care” (Joint Commission Resources: 2003 Comprehensive Accreditation Manual for Hospitals: The Official Handbook. 2003, p. RI-8) and has addressed spirituality and emotional well-being as aspects of patient care. Researchers’ interest in the connections between mind and body (Damasio, 1999; Penrose, 1999) oincides with increasing interest in the holistic view of health care, in which emotional and spiritual needs are considered inextricable from physical and psychological needs (Sherbourne et al. , 1999, pp. 357-63). For example, Standard RI. 1. 3. 5 refers to “pastoral care and other spiritual services” (p. RI-15). The intent for Standard RI. 1. 2. 8, “The hospital addresses care at the end of life” (p. RI-13), refers to “responding to the psychological, social, emotional, spiritual, and cultural concerns of the patient and family” (p. RI-13). Scope of the Study The purpose of the Benjamins Study is to examine the nteraction of religion and spirituality with self-reported health status in a community-dwelling geriatric population. The two main studies in review differ in scope and breadth of patients sampled. The Benjamins Study utilizes the national data base AHEAD, developed by the University of Michigan. The Benjamins Study review found over 1200 comprehensive reviews (Koenig, 2001 ; Larson, 1998) have focused on the association between religion and physical and mental health (Chatter, 2000, pp. 355-67; Ellison ; Levin, 1998, pp. 700-20; Jarvis; Northcott, 1987, pp. 813-24). The Daaleman Study is a regional review of geriatric patients participating in a program at the University of Kansas Medical Center. Daaleman performed a crosssectional analysis of 277 geriatric outpatients participating in a cohort study in the Kansas City area. This study tested the hypothesis from a large continental longitudinal study design to a focused univariate and multivariate logistical regression analysis study design from a specific region of the United States. In a national health survey financed by the U. S. Centers for Disease Control and Prevention, religiously active people had longer life expectancies (Hummer, et al. 1999). These co-relational findings do not indicate non-attendees who start attending services and change nothing else will live eight years longer (See Table 2), but they do indicate as a predictor of health and longevity, religious involvement rivals nonsmoking and exercise effects. Such findings demand explanation. First, religiously active people tend to have healthier life-styles; for example, they smoke and drink less (Koenig, 1999, p. 24; Strawbridge et al. , 2001, pp. 957-61). Religiously orthodox Israelis eat less fat than do their nonreligious compatriots. But such differences are not reat enough to explain the dramatically reduced mortality in the religious kibbutzim, argued the Israeli researchers. In the recent American studies, too, about 75 percent of the longevity difference remains after controlling for unhealthy behaviors such as inactivity and smoking (Musick et al. , 1999, pp. 73-86). Social support is another variable that helps explain the “faith factor” (George et al. , 2002, p. 115). For Judaism, Christianity, and Islam, faith is not solo spirituality but a 7 communal experience that helps satisfy the need to belong. The more than 350,000 faith communities in North America nd the millions more elsewhere provide support networks for their active participants—people who are there for one another when misfortune strikes. Moreover, religion encourages another predictor of health and longevity— marriage. In the religious kibbutzim, for example, divorce is almost nonexistent. But even after controlling for gender, unhealthy behaviors, social ties, and preexisting health problems, the mortality studies find much of the mortality reduction remaining (George et al. , 2000, pp. 102-116). Healthy Behaviors Religious Involvement Social Support (Faith Groups) Health (Absence of Illness) Positive Emotions Hope/optimism (Adapted from: Koenig ; Larson, 1998) Researchers therefore speculate a third set of intervening variables is the stress protection and enhanced well-being associated with a coherent worldview, a sense of hope for the long-term future, feelings of ultimate 8 acceptance, and the relaxed meditation of prayer or Sabbath observance. These variables might also help to explain other recent findings, such as healthier immune functioning and fewer hospital admissions among religiously active people (Koenig, 1999, p. 25; Koenig et al. , 1995, pp. 365-75). Rationale of the study Hospitals have often assigned the responsibility of ddressing emotional and spiritual issues to chaplains or to pastoral teams. Yet others—nurses, physicians, clinicians, and other caregivers—play equally important roles. The hospital staff’s ability to address patients’ emotional and spiritual needs factors into patients’ perceptions of the overall experience of care, the provider, and the organization. Patients have a desire to feel their circumstances and feelings are appreciated and understood by the health care team professionals. Shojania states it as follows, “If patients feel that the attention they receive is genuinely caring and tailored to eet their needs, it is far more likely that they will develop trust and confidence in the organization” (Shojania ; Bero, 2001, p. 160). A comprehensive literature review was completed by JCAHO staff to guide hospital administrators’ management of patients’ emotional and spiritual needs. This review provided the national literature benchmark for hospitalized patients’ emotional and spiritual needs and presents JCAHO’s survey findings on the importance of these needs in patients’ perceptions of care. Three questions are 9 addressed: (Values and Beliefs Respected; RI. 2. 10. May, 2005. Appendices A) 1.
Are patients’ emotional and spiritual needs important? 2. Are hospitals effective in addressing these needs? 3. What strategies should guide improvement in the near future and long-term? The religion factor is multidimensional and therefore, very hard to measure. Although the religion-health correlation is yet to be fully explained Pincus, deputy medical director of the American Psychiatric Association, believes these findings “have made clear that anyone involved in providing health care services . . . cannot ignore . . . the important connections between spirituality, religion, and health” (Pincus, 1995).
Consider the fact that older Americans will more than double in number from 35 million today to 70 million by year 2030. Already, some 6,000 Americans turn age 65 every day in our country. In just 10 years, the number reaching that personal milestone will rise to about 10,000 Americans each day. As hard as it may be for some to admit, the very icons of American youth and the Baby Boom generation will soon become part of the largest Medicare generation in history (Alliance for Aging Research. “Social Security Widow(er) Insurance Benefits” Web site report, 2005). 10 Overview of the study
Religion and spirituality have entered the agenda of research on psychosocial factors in health. Benjamins found over 1200 comprehensive reviews have focused on the association between religion and physical and mental health (Chatters, 2000, pp. 335-67; Ellison ; Levin, 1998, pp. 700-20; Jarvis; Northcott, 1987, pp. 813-24). These studies have separately reported both long-term and shortterm beneficial effects of individual religiousness on physical health status. The goal of this study is to assess the impact (positive or negative) of religion on functional health outcomes.
The Daaleman Study performed a crosssectional analysis of 277 geriatric outpatients participating in a cohort study in the Kansas City area. Patients underwent a home assessment of multiple health status and functional indicators by trained research assistants. A previously validated 5-item measure of religiosity and 12item spirituality instrument were embedded during the final data collection. Univariate and multivariate analyses were performed to determine the relationship between each factor and self-reported health status. The Benjamins Study used the Assets and Health Dynamics Among the Oldest Old Survey, a nationally epresentative, longitudinal data set, to estimate the effects of religious attendance and salience on functional health in the elderly. The primary study hypothesis proposes that religious attendance and salience will be associated with a decrease in functional limitations for older respondents. This review of literature is a small snapshot of findings that represents a variety of national population groups, 11 validated outcome measures, different study designs, various analytical techniques, multiple follow-up periods, and focused geographic regions. 12 Chapter 2: Review of Related Literature A History of Religious Studies in Health Care
Most of the time, a doctor’s advice for successful aging would offer the familiar mantras of good health: quit smoking, exercise regularly, and eat five to seven helpings of fruits and vegetables a day. Yet perhaps the day could be coming when your family physician might prescribe some unusual advice: go to your house of worship, meditate, and pray. In the United States, the traditional boundaries between church and state are blurring with President George W. Bush’s recent initiative to allow faithbased charities to compete for government funding. Family medical providers emphasize medical care for the whole erson, which includes the complete understanding of a patient’s family and living environment. Daaleman completed a survey in 1998 that showed 72% of the physicians interviewed were interested in training in prayer, but only 33% believed in prayer as a legitimate medical practice. King’s research within healthcare settings found that “religious and spiritual beliefs wield substantial influence on patient health benefits, and some may directly affect clinical outcomes” (King, 1994, p. 351). Might the boundaries between medicine and religion be blurring as well? Does the Baby Boomer generation eally want to know this information? According to Keyes (2002) the Baby Boomer generations are better economic consumers and civic citizens, investing in methods and products that improve health outcomes (Keyes, 2002, p. 55) January 1, 2011, is more than just a 65th birthday for the first of the 76 million Baby Boomers in the United 13 States. On this date, Baby Boomers will begin to enter the rolls of many federal programs. This will undoubtedly place a substantial economic burden onto both the government and taxpayers alike. However, it is important to strengthen our research on medicine and religion now in order to repare the nation for the influx of older Americans, as they help to preserve the independence and quality of life of our nation’s seniors (Alliance for Aging: Medicare Report, 2005). Demographics ; Economic Impact So many creative and innovative programs are being implemented by faith communities throughout the nation that we can begin to think in terms of a faith and health movement in America. The objective of the Interfaith Health Program is to nurture this movement, because health is central to the mission of every faith tradition (Gunderson, 2002). The contributions of faith communities to health and ealing have been relatively insignificant in this century. This was due largely to the scientific breakthroughs that gave modern medicine enormous prestige and power. However, concern for healing was never lost in faith communities. This concern was evident in prayers for the sick, the establishment of Jewish and Christian hospitals, medical missions, and the practice of faith healing. Until recently, however, both medical and faith groups have focused almost exclusively on the treatment of disease. The emphasis in the last two decades has shifted from healing to health, from a narrow focus on physical ailments, 14 o the health of the whole person. This shift of emphasis, as welcome as it is, still reflects a narrow individualism within our culture. The leading edge of the faith and health movement is focusing attention on the health of communities. A bipartisan effort in congress was pushed by the United Jewish Federation in partnership with other faith groups to pass a critical piece of legislation call “The Return to Home” bill. Under the “Return to Home” legislation, most hospitalized elderly patients of all faith groups living in senior facilities and who are temporarily hospitalized will not be prohibited by their HMO s from eturning to their local communities for post-hospitalization recovery and rehabilitation (Koenig, 2004, p. 43). Promoting health is the challenge both religious and health leaders face as America ages into the next century. No Americans want to be without modern medical advances, but health is more than the absence of disease. It involves mental and spiritual well-being as well as physical health. It involves the health of communities as well as the health of individuals. Physicians should be aware of the role religion plays in how patients cope with illness. Scientists are only now beginning to discover the owerful effects the mind and social relationships can have on health outcomes. By reclaiming health as part of their mission, faith groups once again are partners with other community agencies in improving health (Koenig, 1999, pp. 42-43). Where do the healthcare policy makers need to focus their efforts? First, more than half of the leading causes of death in this country are preventable. Deaths 15 due to alcohol, tobacco, and inactivity would decrease significantly if lifestyles were modified. The 10 Leading Medical Causes of Death… Deaths Lifestyle Factors Deaths Leading to Half of Them Heart Disease 20,000 Tobacco Cancer 505,000 Diet, Sedentary 300,000 Lifestyle Cerebrovascular Disease 144,000 Alcohol 100,000 Accidents 92,000 Infections 90,000 Chronic Pulmonary Disease 87,000 Toxic Agents 60,000 Pneumonia and Influenza 80,000 Firearms 35,000 Diabetes 48,000 Sexual Behavior 30,000 Suicide 31,000 Motor Vehicles 25,000 Liver Disease, Cirrhosis 26,000 Illicit Drug Use 20,000 AIDS 25,000 400,000 16 Total 2,148,000 Total 1,060,000 (McGinnis ; Foege, 1993). In addition to promoting lifestyle changes, faith groups share with public health agencies a commitment to social justice as this relates to health.
There is a clear connection between socioeconomic status (SES) and health. No matter how SES is measured, persons who are impoverished, homeless, or vulnerable are likely to have negative health patterns. Health is a goal for everybody, but socioeconomic status factors undermine it in spite of personal efforts. Because health is a goal for all, community members have a moral imperative to address socioeconomic status (McGinnis, 1993, pp. 2207-2211). Public health agencies and faith communities share social justice as a fundamental core value. This provides a basis for collaboration. Community-level systemic change n addressing problems like substance abuse and violence can best be achieved through partnership. Aging Stats: • In 10 years, 10,000 Americans will turn 65 each day. • By 2030, the older population of the United States will have doubled to more than 70 million people. • By 2050, the “oldest old” (over age 85) will increase almost fourfold, from 4 million today, to nearly 19 million by 2050. 17 Boomer Health Care Needs: • • • • • • In 2011, hospital spending is expected to reach $885. 2 billion (CMS, National Health Expenditures, 2002). Prescription drug expenditures for 2011 are expected to reach $435. 2 billion (CMS, National Health
Expenditures, 2002). Nursing home expenditures will reach an expected $164. 4 billion in 2011 (CMS, National Health Expenditures, 2002). It is estimated that by 2010, 2. 6 million Americans will be moved to a nursing home (Data from Bureau of US Census, 2005). By 2010, expenses related to Alzheimer’s disease are expected to increase by 54. 5% to $49. 3 billion (Medicare and Medicaid Costs for People with Alzheimer’s disease. Washington, D. C. : April 2001: The Lewin Group). By 2050, the need for direct care/long-term care workers will grow from 4. 2 million workers to 8. 6 million, though this workforce is expected to increase nly slightly (HHS, The Future Supply of Long-Term Care Workers in Relation to The Aging Baby Boomer Generation, Report to Congress, May 2003). Retirement and Social Security Facts • Beginning in 2010, 76 million Baby Boomers will be retiring over the next 20 years (Social Security, The Future of Social Security, July 1999). 18 • • • • • • • In about 30 years, there will be twice as many older Americans, though the workers paying into Social Security per beneficiary will drop from 3. 3 to 2 (Social Security, The Future of Social Security, July 1999). Social Security benefit payments will exceed taxes in 018 (Social Security, The Future of Social Security, July 1999). If nothing is done to strengthen Social Security, its trust funds will be exhausted by 2042 (Social Security, The Future of Social Security, July 1999). In 1950 there were seven persons of working age for every person 65 and older; by 2030, there will be fewer than three (Department of Labor, Aging Baby Boomers in a New Workforce Development System). By 2008 there will be about 1. 1 million more 45 to 54 year old economically disadvantaged adults than in 1998 and over 2 million more disadvantaged who are 55 and older (Department of Labor, Aging Baby
Boomers in a New Workforce Development System, 2004). Currently, there is a 40% chance that an American will be poor at some time after the age of 60 (AARP, Beyond 50 Report, 2004). An estimated one third of all people over age 65 cannot work due to their health (National Center for Health Statistics, 2000 National Health Interview Survey). Medicare Facts: • In 10 years, Medicare could eat up as much as 70% of all federal tax income. 19 • • • Medicare spending for individuals with Alzheimer’s disease are expected to spike from $18. 2 billion in 2002 to $33 billion in 2010 (Report Commissioned by Alzheimer’s Association and conducted by Lewin
Group, Medicare and Medicaid Costs for People with Alzheimer’s Disease, 2001). The share of Medicare spending devoted to beneficiaries with Alzheimer’s disease is projected to rise to 15. 7% in 2010 (Report Commissioned by Alzheimer’s Association and conducted by Lewin Group, Medicare and Medicaid Costs for People with Alzheimer’s Disease, 2001). Diabetes treatment currently consumes one third of Medicare spending. The prevalence of diabetes in the United States is likely to increase by 165% by 2050 (CMS, National Health Expenditures, 2002). Science and Religion With the full knowledge of the demographic shifts in ur society, proponents of recent research into the role of spirituality in health believe it is time for those boundaries to disappear. Numerous studies published in peerreviewed journals have shown religious faith and participation in organized religion offer benefits for healthy aging. People with a strong personal faith who regularly attend religious services generally have lower blood pressure; are less likely to suffer from depression; have a greater sense of well-being; have stronger immune systems; and live longer-23% longer, according to a longterm study by Strawbridge (1997) and other researchers 20 ublished in the American Journal of Public Health (pp. 95761). Religious faith seems to increase the ability of older people to cope with illness, disability, loss, and their own mortality. In a study published in 1992 in the American Journal of Psychiatry, Harold G. Koenig, Director of the Center for the Study of Religion/Spirituality and Health at Duke University, and colleagues surveyed men hospitalized with serious illness. They found those men who used religion to cope with their illness had much lower rates of depression and reported a better quality of life than those using nonreligious coping methods or who reacted egatively to their situation. In addition, religious people seem to spend less time in the hospital. In a study published in the Southern Medical Journal in 1998, Koenig and colleagues found subjects who attended church at least once per week were 43% less likely to have been admitted to the hospital in the preceding year than nonchurchgoing subjects. Plus, any hospital stays they did have were markedly shorter (Koenig, 1999, pp. 925-26). Data like this seem particularly meaningful in light of the growing expenses of our healthcare system, which will worsen as the Baby Boomer generation ages. Koenig 2001) believes doctors ought to take a spiritual history of patients with a serious medical illness (pp. 81-82). Duke medical students are instructed on the importance of physician/patient knowledge of how a person’s religious beliefs could help or hinder their ability to cope with their illness. In some areas of the United States, up to 90% of patients rely on religion for comfort or strength during times of serious illness (Koenig, 2001, p. 81). Koenig and 21 others research supports more of a direct connection between the delivery of health care and religious communities. JACHO has supported this research by roviding public policy directives and practical assessment tools that should be taken during a hospital stay to establish a baseline for each patient (Appendices E: JCAHO Baseline Spiritual Assessment). However, not all researchers find the evidence linking religion to good health compelling. Richard P. Sloan, Director of the Behavioral Medicine Program at ColumbiaPresbyterian Medical Center in New York, believes the scientific evidence supporting the association between spirituality and good health is weak. He notes the results of many studies have not been consistent. Some of the studies have shown religious attendance is associated with onger life, but others have not. In addition, the studies tend to vary on how they define religious and spiritual activity, leading to difficulty in comparing them. In his paper on this topic published in the Feb. 20, 1999, issue of the journal “Lancet”, Sloan wrote, “Even in the best studies, the evidence of an association between religion, spirituality, and health is weak and inconsistent. ” He also points out there are ethical problems with a physician recommending religion to patients. Sloan states, “Spirituality is a complex and multi-dimensional part of the human experience that hould be assessed by professionals. ” Daaleman found within the American Medical Association, “Family physicians are perceived as being unqualified or untrained to discuss spiritual and religious issues with patients (Daaleman, 2001, p. 549)”. The ethical dilemmas have 22 developed between science and religion and will be addressed later in this paper. A Review of Religion in Medical School Programs The Relaxation Response: Harvard Medical School For people uncomfortable with traditional religions, work by Herbert Benson, an Associate Professor of Medicine at Harvard Medical School and founder of the Mind/Body
Medical Institute, suggests you can enhance your spirituality and your health without joining a traditional church or synagogue. In the early 1970s, Benson defined the relaxation response as the opposite of the fight-or-flight response. It brings about a slowed heartbeat, lowered blood pressure, and a reduction in stress rather than the opposite (Benson, 1997). Drawing on non-Western religious traditions, the relaxation response is triggered through the spiritual practice of many techniques, including meditation, yoga, progressive relaxation, and autogenic training. In numerous studies published in the 1970s and 980s, Benson and colleague’s demonstrated regular use of the relaxation response led patients to overcome a variety of stress-related illnesses, such as insomnia, migraine headaches, and hypertension. Patients also reported increased feelings of spirituality. Although the relaxation response works no matter what the practitioner’s spiritual beliefs, Benson is an avid supporter of religious faith. “There is a tremendous amount of literature that belief enhances healing,” he points out, referring to the placebo effect, which he calls “remembered 23 wellness” (p. 25). Studies have shown that anywhere from 0 to 70% of patients with certain non-life-threatening illnesses or conditions will recover just by taking a “sugar pill” or other form of placebo. If faith in the medical establishment can yield such positive results, Benson reasons, combining it with faith in a higher power that can assist with healing can only help the brain remember how it felt to be well (Benson, 1997). Aging as a Spiritual Journey: Loyola University Loyola University Medical School proposes the question “Is the only goal of spirituality in aging to maintain health (Leder, 1997)? ” A growing number of people think otherwise.
They have begun advocating a different approach to aging: treating the later years as a new, unique stage in life rather than trying to extend youth. Drew Leder (1997), a professor of philosophy at Loyola University in Maryland and author of the spiritual workbook Spiritual Passages: Embracing Life’s Sacred Journey, has drawn upon the spiritual beliefs of many different cultures to build a model of aging as an opportunity for spiritual growth. Leder found the most sacred traditions emphasize one of two roles for older adults: embarking on a quest for spiritual growth or mentoring the younger generation. One
Hindu tradition urges the elderly to leave behind their comforts and possessions and resort to the forest to seek enlightenment. On the other hand, Native American cultures expected older people to become elders, to use their accumulated knowledge and wisdom to advise and guide the tribe. Leder and other proponents of a spiritual approach to aging call their blend of these ideas spiritual 24 eldering. Some advocates have even begun creating spiritual eldering residential communities, constructing space that encourages individual reflection and meditation while supporting mentoring and volunteerism programs to nable the elders to offer their wisdom for the benefit of society (Leder, 1997, pp. 277-80). Leder believes even the ill elderly who are unable to volunteer or travel to spiritual retreats can find solace in the spiritual eldering process. “Even if you don’t stay healthy, you can use that as part of your spiritual growth. Disability causes people to seek out social and spiritual wholeness” (Leder, 1997, p. 232). An inward spiritual journey can help ill or disabled people come to terms with death and dying, relieving anxiety about mortality. And those with a belief in a higher power can still serve others by praying for them nd society in general (Leder, 1997, pp. 232-33). Extrapolating from the scientific literature, perhaps anything that reduces stress and anxiety can improve the quality of our lives. Whether older people achieve inner peace through attendance at a Christian church or Jewish synagogue, through meditation designed to elicit the relaxation response, or through contemplation of spiritual matters and an acceptance of mortality, the effect is most likely similar. The real goal of successful aging should be to enjoy the extra years of life that advances in Western medicine have brought us (Leder, 1997, pp. 241-42).
Sloan would not disagree with Leder and others, but argues it is not the “role of the physician to play spiritual or religious provider in a time of clinical concern” (Sloan, 1999, p. 667). Spiritual assessment and intervention should come from a professional Chaplin, not the medical staff. 25 Faith considered a life-promoting factor: Emory University According to Gary Gunderson, director of Emory University’s Interfaith Health Program, there is no time like the present for elevating the positive in health care by assessing and promoting factors which allow for optimal health outcomes. At a recent conference, Gunderson uggested rather than preventing, allaying or eliminating symptoms of disease, researchers look at factors that promote health. Living life to its fullness is not a new idea, but the current way of thinking about it is in terms of spiritual awareness (Gunderson, 2002). With the world of public health research in a state of discontinuity he argued, the glass-half-full approach holds significant promise for the patients’ healthcare professional and clergy serve. Gunderson began by setting the context for what we have called the “Faith & Health” movement and by addressing issues of accountability and alignment. Health care rganizations are incapable of fulfilling their core mission by themselves; the answer is alignment with their stakeholders and is profoundly dependent on leaders operating at the boundaries between systems. Four issues have emerged regarding the complex and ambiguous religious history in the U. S. health infrastructure: (1) the link between private spirituality and private wellness; (2) the alignment of religious structures and public health; (3) renegotiations of social/political responsibilities; and (4) congregational vitality in community (Gunderson, 2002). Many faith-based initiatives are developing community 26 ealthcare support networks, meeting the needs of the poor and uninsured in large urban areas. Physician Relationship: Religion and Health at St. Louis University Physician beliefs and attitudes have been studied as they relate to religion in medicine at St. Louis University’s School of Medicine. The literature suggests the myriad physician beliefs about psychosocial factors are reflected in approaches to patient care. Koenig et al. (1998) showed physician beliefs about the importance of religion to older patients were the primary correlates of physician attitude toward religious inquiry in the clinic (Koenig, 1989, pp. 41448). Olive (1995) found among internal and family medicine physicians with a professed religious commitment, intrinsic religiousness and religious denomination were powerful predictors of religious discussions with patients (pp. 1249-55). Surveying preclinical medical students, religiousness was shown to be the best predictor of views about praying with patients, conducting a spiritual history, and patient desire for spiritual inquiry (Chibnall, 2000, pp. 102-08). Recently, Ellis et al. (1999) showed the most common self-reported barriers to clinical spiritual inquiry among family physicians included eliefs about lack of time and inadequate training, difficulties in identifying patients receptive to spiritual discussions, and fear of appearing to proselytize (pp. 10509). Interpersonal discomfort with non-biologic topics, views on physician job role, and beliefs about religion’s relevance to health may also drive attitudes and behavior 27 regarding religion and medicine (Chibnall, 2000, p. 661; Barnard, 1985, pp. 272-86). Building on the previous work completed at St. Louis, Chibnall et al. explored religion and medicine issues among a variety of specialists, including surgeons and neurologists.
As part of the study an attempt was made to predict physician religious behavior in the clinic from beliefs and attitudes, including physicians’ own personal religiousness. In addressing these issues, the study’s goal was to understand factors facilitating or impeding physician attention to religion in the clinic. Surprisingly, the majority of physicians sampled did not report personal discomfort with religious discussions in the clinic. The surveyed physicians appeared positively disposed toward a religion-health relationship. Yet, few physicians engaged in religious behavior in the clinic.
These findings are incompatible and indicate a discrepancy between beliefs and behavior. This study’s result suggests that this discrepancy is mediated primarily by personal comfort with bringing the topic into the clinic. The findings of Ellis et al. (1999) are not dissimilar (pp. 105-108). Of the top five barriers cited in that study, four appear related to issues of comfort: lack of training, uncertainty about identifying responsive patients, concerns about proselytizing, and uncertainty about managing spiritual issues. The concern most commonly endorsed by the physicians in the St.
Louis study was a negative patient reaction (Chibnall, 2001, p. 376). The studies results do not support the notion that the strength of a physician’s personal religious commitment is an important predictor of spiritual behavior in the clinic. At 28 least two other studies have suggested the physician’s own religious commitment may influence attention to religion in the clinic (Maugans, 1991, p. 11-16; Olive, 1995, pp. 124955). This difference may reflect, in part, disparities in sampling, demographics, question wording/variable selection, and statistical analysis among the studies. In his study, 59% of the sample described themselves as religious, yet this group was no more or less likely to pursue religious discussion with patients than their nonreligious peers. This is consistent with the group’s lack of concern over proselytizing (only 15% endorsed this concern) and suggests they are able to differentiate proselytizing from psychosocially based clinical religious inquiry (Chibnall, 2001, pp. 374-79). To the extent that beliefs and practices counter to spiritual inquiry are developed or reinforced in medical training, attention to these components may increase the omfort level of the physician in discussing religious topics. At least one study has shown increased exposure to religious topics in medical school predicts a more positive attitude toward the importance of spiritual inquiry with patients (Chibnall, 2000, pp. 102-08). The St. Louis study cannot determine the extent to which critical beliefs are learned, personality-based, or “naturally selected” by the medical system. The medical school continues to evaluate the interactions between medical students and the professional chaplaincy. Future prospective research would add much needed light to the eligion/health speculations. 29 International Center for the Integration of Health and Spirituality Thomas R. Smith, 2004 interim president and CEO of the International Center for the Integration of Health and Spirituality, pointed out in these days the realms of science and religion are “no longer mutually exclusive. ” (International Center for the Integration of Health and Spirituality, 2004, p. 1). Smith told the audience the current use of church attendance in defining religious people was inadequate, saying increased longevity enjoyed by those attending church weekly did not increase incrementally with ttendance. “Longevity doesn’t spike until it reaches oncea-week frequency”, he said, “so the implication is that attendance is not the main issue” (International Center for the Integration of Health and Spirituality, 2004, p. 8). Centers for Disease Control Outlook on life is also integral to this new paradigm, according to Corey Keyes, visiting scholar in faith health leadership at the Centers for Disease Control and Prevention, or CDC. The current view of health, he said, implies healthy people are better members of society. Healthy people “are better economic and civic citizens,” said Keyes.
But it’s more accurate to say true health is more than the absence of illness, he explained (Keyes, 2002). Keyes explores methods of defining and measuring levels of health in disease and symptom-free people. As well as, determining if any benefit exists in moving up the health-status ladder. 30 Using two attitudinal measures and a list of healthy symptoms, Keyes charted subjects on a five-point continuum ranging from languishing to flourishing. When controlled for the presence of four serious mental disorders such as manic depression, panic, generalized anxiety and alcohol dependence, people with lower levels of mental llness showed higher levels of health (Keyes, 2002). Health levels also affected daily living and work productivity. Those in the flourishing category, for example, were about one-third as likely (3. 4 percent) to have missed a half-day’s work in the previous 30 days as those assigned to the languishing category (11. 3 percent). “Anything less than complete mental health shows reduction in things we value as a society,” said Keyes, adding that increased data supporting the “cause-of-life” approach, one in which health is considered more than the absence of disease, could have a huge impact on mental ealth programs (Keyes, 2002). What Strawbridge suggested in a national conference for physicians, “There are two things that I think we know for sure about religious involvement and health outcomes. ” Idler talked about the first one, which says religious involvement predicts longevity. The second thing we know from a number of studies is people who are religiously involved have better health behaviors than those who are not, particularly in terms of not smoking and not drinking excessively and not being depressed. Sloan (1999) states that the real question is, “did they have those better health behaviors and become religious, r did their religiosity have something to do with their better health behaviors (Sloan, 1999, p. 666)? ” Sloan’s ethical 31 arguments of physicians prescribing religious interventions centers around the following focus: “Would I recommend to a patient marriage just because it will lengthen his life? Statistics prove the health benefit of marriage in every scientific study! ” (Sloan, 1999, p. 667). Sloan widely publishes his viewpoint as the trivialization of faith by religious leaders that have an influence on the medical institutions educating the nation’s physicians. If you think the first statement made by Idler is true, he healthy behaviors come first that leads to a reduced risk of mortality, but then that in turn is associated with religiosity or spirituality, and then you would have a model like this. That is why statistical studies show the effect of religious involvement on longevity; most researchers adjust for health behaviors. When Strawbridge adjusted for the health behaviors there was still a significant effect. Perhaps religiosity has something to do with either maintaining or improving healthy behaviors, like not smoking, not drinking excessively, and that in turn leads to lower mortality (Strawbridge, 2003).
Joint Commission on Accreditation of Healthcare Organizations (JCAHO) JCAHO states that spiritual assessment should, at a minimum, determine the patient’s denomination, beliefs, and what spiritual practices are important to the patient. This information would assist in determining the impact of spirituality, if any, on the care/services being provided and will identify if any further assessment is needed. The standards require organizations to define the content and scope of spiritual and other assessments and 32 the qualifications of the individual(s) performing the assessment. The Commission’s goal is to provide at least ome baselines to clinical assessment of patients under physician care. Examples of elements that could be but are not required in a spiritual assessment include the following questions directed to the patient or his/her family: (Appendices E: JCAHO, Spiritual Assessment) • • • • • • • • • • • • • • Who or what provides the patient with strength and hope? Does the patient use prayer in their life? How does the patient express his/her spirituality? How would the patient describe his/her philosophy of life? What type of spiritual/religious support does the patient desire? What is the name of the patient’s clergy, ministers, haplains, pastor, and rabbi? What does suffering mean to the patient? What does dying mean to the patient? What are the patient’s spiritual goals? Is there a role of church/synagogue in the patient’s life? How does your faith help the patient cope with illness? How does the patient keep going day after day? What helps the patient get through this health care experience? How has illness affected the patient and his/her family? 33 JCAHO has acknowledged patients’ “psychosocial, spiritual, and cultural values affect how they respond to their care” (Appendices A: Joint Commission Resources: 2003 Comprehensive Accreditation Manual for Hospitals:
The Official Handbook. 2003, p. RI-8) and has addressed spirituality and emotional well-being as aspects of patient care. Researchers’ interest in the connections between mind, body and spirit directly relates with increasing interest in the holistic view of health care (Clark, 2003, p. 659). For example, Standard RI. 1. 3. 5 refers to “pastoral care and other spiritual services” (p. RI-15). The intent for Standard RI. 1. 2. 8, “The hospital addresses care at the end of life” (p. RI-13), refers to “responding to the psychological, social, emotional, spiritual, and cultural concerns of the atient and family. ” (See Table 3) JCAHO states that hospitals have “historically assigned the responsibility to address emotional and spiritual issues to chaplains or to pastoral teams. ” However, the accreditation-body realizes nurses, physicians, clinicians, and other health care providers play equally important roles. JCAHO’s position in the report states, “The hospital staff’s ability to address patients’ emotional and spiritual needs factors in to patients’ perceptions of the overall experience of care, the provider, and the organization” (Clark, 2003, p. 659). For example, s Paul Alexander Clark, reported: “Patients need to feel that their circumstances and feelings are appreciated and understood by the health care team member without criticism or judgment from the hospital staff. JCAHO states that a patient’s trust and confidence in 34 the organization increases as they receive genuine care, tailored to meet their needs” (Clark, 2003, pp. 659-70). The organization provides some very general guidelines and suggestions to hospital staff dealing with spiritual matters. Investigators continue to support these documents with hospital survey data that has a positive orrelation with staff concern for the patient’s, or patients’ spiritual needs. Koenig (2001) found in some areas of the United States, up to 90% of patients rely on religion for comfort or strength during times of serious illness (p. 81). Koenig et al. (2001) found the religious coping behaviors include prayer, inspirational reading, participating in worship services and seeking support from clergy or congregation (p. 82). In studies that have objectively examined these behaviors and their relationship to health status, a connection has often been found. Koenig (2004) expounds on the religion connection to health in his book,
Faith in the Future, that “one way God heals the body (through our faith and belief in God) to boost those natural healing mechanisms, which are a part of the created order, to defeat disease and illness. Sometimes healing doesn’t mean that the cancer leaves the body, but the individual experiences a healing self or family relationship, creating closeness to God (p. 94). The Joint Commission wants the physicians and hospital to be aware of the religious significance. The suggestions by JCAHO were established as guidelines for healthcare practitioners as they address meeting the needs of hospitalized patients. See Table 4) 35 Patient Satisfaction Survey Patient satisfaction data were derived from the Press Ganey Associates national databases. Patient satisfaction with the experience of care is assessed through a questionnaire mailed shortly after a patient’s discharge from an acute care facility. The survey instrument uses a five-point Likert-type response scale (1 = very poor; 2 = poor; 3 = fair; 4 = good; 5 = very good), which provides reliable (Cronbach alpha score, 0. 98) and valid measures of patient satisfaction. The standard survey includes 49 questions in 10 separate areas, covering the entire patient xperience from admission to discharge. One of the questions asked to the admitted patient’s addresses “the degree to which staff addressed your emotional/spiritual needs. ” Analyses utilized Press Ganey’s 2001 National Inpatient Database, containing data for 1,732,562 patients, collected from January 2001 to December 2001 and representing 33% of all hospitals in the United States and 44% of all hospitals with more than 100 beds” (Clark, 2003, p. 660). JCAHO Results: Emotional and Spiritual Directives JCAHO’s policy staff revealed parallels between perceptions of emotional and spiritual needs in a national review.
Definitions of spirituality consistently include the psychological concept of a search for meaning and hope (Idler, 1997, pp. 306-16). For patients who identify spiritual needs, those needs directly involved a range of emotions experienced during hospitalization, desire to maintain formal religious practices. Thus, alleviating fear and loneliness for that patient and enhancing the presence of 36 God (Koenig, 1992, pp. 1693-700). Koenig has published many groundbreaking findings from the Center for Religion/Spirituality and Health, influencing the Joint Commissions religious initiatives: 1. People who regularly attend church, pray ndividually, and read the Bible have significantly lower diastolic blood pressure than the less religious. 2. People who attend church regularly are hospitalized much less often than people who never or rarely participate in religious services. 3. People with strong religious faith are less likely to suffer depression from stressful life events, and if they do, they are more likely to recover from depression than those who are less religious. 4. The deeper a person’s religious faith, the less likely he or she is to be crippled be depression during and after hospitalization for physical illness. 5.
Religious people have healthier lifestyles. They tend to avoid alcohol and drug abuse, risky behavior, and other unhealthy habits. 6. Elderly people with a deep, personal (intrinsic) religious faith have a stronger sense of wellbeing and life satisfaction than their less religious peers. This may be due in part to the stable marriages and strong families’ religious people tend to build. 7. People with strong faith who suffer from physical illness have significantly better health outcomes than less religious people. 37 8. People who attend religious services regularly have stronger immune systems than their less religious counterparts. . Religious people live longer. Emotions and spiritual needs also interrelate on a clinical level. Spirituality has been shown to be associated with decreased anxiety and depression (Kiecolt-Glaser, 1995, pp. 269-74). The Systems of Beliefs Inventory tool was developed to measure spirituality and religious practices in medical populations recognizing the overlapping emotional, cognitive, behavioral, and social elements of spirituality (Holland et al. , 1998, pp. 14-26). It should be noted that emotions and spiritual needs are consistent with patients’ perceptions of a single self where all needs intermingle (Fagerstrom e
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